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For the ankle placement or rotation, you will be um facing these problems very, very commonly. Uh Again, my name is Mohamed Hashem and I'm a photo directly consultant in Northwest London Wickham Park Hospital. Uh And this is where I come from. And this is the youtube channels where all the lectures and education activities will be there. Uh do subscribe and follow them and um you will be updated with every new education and event or activity which will be on the tube. So my youtube channel and also be an official youtube channel. Perfect. So starting with the first one today is ankle arthritis and ankle arthritis. Um is is pretty small tricky biomechanical points which I need you to understand as any form of arthritis. The patient will be coming to you um complaining of pain, limited range of motion, some impingement, especially on dorsiflexion. Very common complaint. He come to say to you that uh I II find difficulty going up and down the stairs. It's very difficult to me to climb the hill or go, go uh uphill, it's very, very difficult. Um maybe a history of pretrauma or a ligamentous injury or recurrent sprain, the commonest form of ankle arthritis as expected will be a posttraumatic ankle arthritis. And that's why ankle fracture fixation is very, very important need to be done. Uh Always by a senior uh uh surgeon and you need to restore the ankle perfectly. And we'll understand now why. Uh when you look at the patient, you found that the patient walking, always with a stiff ankle gait, he couldn't allow the ankle Dorsey or blunt flex. So we we normally expect dorsi flexion to have a he strike at the start of the gate, then blunt flexion to get the foot flat on the ground. Then more planar flexion when you're towing off in the gate. So the main three rockers of the gait, he rocker when you do a he strike at this moment and your ankle will be in dose flexion, then a flat foot when you're doing the ankle rocker, then a two off when you're doing a two rocker or 4 ft rocker. So with ankle arthritis, because this movement is very stiff, the patient cannot Dorsey or blunt a flex. He be losing at least the 1st and 3rd rocker. So you walk with just a stiff ankle gait. Uh You can obviously see a deformity, commonly see that it's a varus deformity, but sometimes the valgus deformity, you will see a clear deformities, especially in the uh from behind the patient. When you examine the patient actively and basically, you will have a limited range of motion. Unsurprisingly, then when you start to feel he will be tender to touch, you need very carefully to check stability because with the stability, this will dictate your your treatment. So if you plan to do some treatment for this ankle arthritis, stability will be one of the dictation. Will you fuse or replace this ankle? You have to check the subtalar joint because again, it's another um element in the, the in the in uh in the management plan. So with Subtalar arthritis, the option to fuse the ankle is not there, you have to try to replace this ankle because fusing the ankle with the arthritic. Subtalar means that subtalar arthritis, we need fusion very soon and you intubation was very stiff segment. So a quick look on the basal anatomy which will explain to us about uh the difference in ankle arthritis and any any other arthritis. It's very expected for the ankle. It's a small joint compared to the knee or the hip uh to have an arthritis more commonly. But the the surprise is not the ankle is less arthritic, more uh less athletic than the knee or hip. And the knee and hip gets more primary arthritis than the ankle. And why especially if I told you that the ankle articular cartilage just one thickness while um cartilage for the knee is 2 to 3. So imagine more thick cartilage, wider joint space for knee and hip and still ankle is less commonly to have an arthritis, uh, primary osteoarthritis than the hip or the knee. The answer would be coming in the biomechanics to understand how the ankle uh works and how the ankle, uh, uh uh behalf. So basically, to understand the biomechanics, uh when you're putting a load in your joints. So for the heavy knee, they load by, by point loading, point loading means your load is going on one point at certain, at, at, at, at every stage of weight bearing. So if I'm standing now with my knee extended, there is a point where it's a point contact between the media femoral condyle and mainly the media femoral condyle and the medial tibial plateau and a point for the later femor Condy and later tibial plateau. And because the media femoral condyle is more, is going more distal, there is more loing in the media side than the lateral side. And this explain to you why the media arthritis in the knee is very common than the lateral arthritis in the knee, lateral compartment, arthritis in the knee. So in the hip, you're just going, there is the weight bearing surface uh of the head, there is a sore seal of the acetabulum and you're bo bo both in a point loading between the sore seal of the estab and the weight bearing head area of the head. Same in the knee. You have the medial femoral condyle and the medial tibial plateau in the medial compartment and lateral femoral condyle, lateral tibial plateau in the lateral compartment. And you're putting a point loading on both of them. Well, in the ankle is a surface loading. It's not a point loading. So basically very confined system with the surface of the tibial plateau, medial mal and the lateral mall. And it's the talus is just acting and confined inside. It is a very conformed joint and because of the conformity of the joint, the loading is a surface loading. There is no b loing in the ankle. Again, ankle is a smaller ankle cartilage is thinner. And though that ankle is less commonly to have a primary osteoarthritis and all, all, all the time, you have to ask yourself why and the answer of why is though the knee and hip are more broader. So the larger surface area thicker cartilage 2 to 3 compared to one in the ankle, they still getting arthritis, primary arthritis more than the ankle. And that's because of the way of loading for the hip. You're loading a boy loing between the sore seal of the acetabulum and the head bearing weight bearing area in the head. And this is the point loading and that's why this is a common area to collapse with a VN. It's very common to have a central arthritis of the ankle. Uh I'm sorry, the hip for the knee, you have the medial femoral condyle prominently more distal loading on a point at the medial tibial plateau and lateral femoral condyle bo bo loading at a point at the lateral tibial plateau. So point loading media and lateral media is more prominent. That's why medial compartment arthritis are more common than the lateral compartment arthritis in the knee. While in the ankle, there is no point loading, you do a surface loading. So very conformed surface of the tibial blood formed medial man and lateral man. And the terus is just sitting inside very conformed. There is very congruent joint. That's why you do a surface loathing rather than a boy loading. And from here, you need to understand why posttraumatic arthritis is the most common because with every one and a movement, you lose 40% of this conformation and you go from a surface loading to a point loading. And that's why posttraumatic the ankle is very commonly to get arthritic. So if you compare the primary osteoarthritis, ankle is less common to have a primary osteoarthritis compared to a hip or knee. While posttraumatic ankle is commoner to have posttraumatic arthritis compared to a hip or knee. So if you have a tibial plateau fracture, your chance to get an arthritis and the time to get the arthritis in is much less than if you have a uh a mauc ankle fracture. Uh So you will get a very early and very commonly posttraumatic ankle arthritis. That is why because you just lose the surface loading and go to a point loading like what happens in the head and knee and the normal, I hope this point is clear. So if you come to about physiology, so as you see, 80% of ankle arthritis is posttraumatic. And I think you now understand you understand now, biomechanically why abasic not that common, which is the primary osteoarthritis. And again, I explain to you why then it's, it's the other way is to get it. Anflam arthros like rheumatoid arthritis. So how will we treat an ankle arthritis in all foot and ankle conditions? We always start with non operative treatment or conservative treatment. So to help the patient with the walking, you give him a single roer shoe and the rocker shoe basically has a bump in the ba in the bottom and this bump in the bottom just allow the patient to move from a third to first rocker without disturbing at the ankle. So reducing the load over the ankle, you may help the patient with some physiotherapy pain management, intraarticular inje injection, especially steroid injection and they do help the patient a lot. So the second stage, if the patient doesn't respond to this or if the patient is mainly has a mechanical symptoms, so you can go and do an arthroscopic debridement because the commonest complaint of this patient, as you see here is an anterior osteophyte which is causing anterior impingement, making him difficult to weight, bear making him difficult to do dorsiflexion to walk up hills or hills or uh to go upstairs. So you may go and do a colectomy for this os uh um osteophyte. So get this osteophyte divided AOS have a look in the joint, do a proper wash of the joint debride. Any osteophyte you can see and this does help the vision as well. But definitely as a temporary measure. If you go to more than this, if the patient, if the patient has immediate or lateral arthritis, so confined to one place, this is the time you can do a supra manar osteotomy, just as a joint preservation surgery like we do in the high tibial osteotomy in the knee. Then the end result, if this all, if all these fails or the patient has an advanced arthritis and there is no way to, to try any joint preservation, the option would be either to replace or to fuse. So we speak about every option, the uh uh uh in details. So if we start with the communist option and the most successful option at the moment, which is Arthur releases or fusion, you do a fusion. Definitely in a young man, in a young young man, especially man, young young womans with the womans, especially because of the of of the way of the bone, the bone quality and the way the bone behalf we more we more to to replace them. So young man, mostly a manual laborer. So someone who is doing a lot of uh uh manual activities because till the moment we are not. So um uh confident in the results of ankle replacement with an high activity or high loading. So if a patient young manual uh walker and with severe arthritis, the option would be for fusion. Definitely, if the patient has an infection, there is no point uh or there is no space for any replacement, replacement will fail. So, if the patient has an infection, you eradicate the infection, give the vision a proper treatment to control the infection. And this is the time you go for a fusion rather than a replacement trauma because with the trauma, the joint will be deformed. So replacing the joint will not be easy. But actually at the moment, this point is not that valid because we now can do ankle replacement in posttraumatic arthritis. And there is a more variability, more versatility and uh and uh uh uh in the ankle replacement, uh implants and options end of the, the because we all agree that there is no way to put a, the component over an E VNT because with necrotic, the, the, the the way for this uh or I'm sorry, the chance for uh the, the uh component to collapse and uh and and subside is very high. So no one will, will replace an E VN uh as a salvage if they failed, failed arthroplasty. So, Arthrodesis remains an option at any time. So if you do other arthroplasty, revise it for infection or something and you have to go for another division. So you can salvage this with an um uh arthrodesis. How w where you both your ankle, the arthrodesis. So you have to put the ankle and in neutral dos. And this is very, very important. Most of the causes of failed arthrodesis or painful arthrodesis is if you put the foot in blunt flexion because when you put in the foot in, in, in the bottom foot, but when you put the foot in plantar flexion, you're loading a certain point in the ankle. And that's why the fusion always uh fail and always painful. But when you keep the the ankle in neutral dorsiflexion, this means you're losing the whole surface. The chance for healing and fusion is very good. And the the problem of pain or problems after that is not that you need to keep the ankle in five degree valgus, which is the natural for it. And you need to keep the ankle in, in external rotation because with extended rotation is easy for you to clear the ground. So if the ankle is just straightforward or internally rotate, this means clearing of the ground during the gate is difficult. So you need to keep the ankle in five degrees extended rotation. So it will be easy for the patient to clear the the the the ground, clear the foot from the ground without a lot of movement of the hip or knee. So you keep it in neutral dorsiflexion just to load the whole surface of the joint, allow it to unite a fuse and don't have any problem or uh or vein after that. Number two and five degrees valgus because it's the natural alignment of the hind foot and five degrees extended rotation to make clearing the foot from the ground during the gait easy without much movement from the hip or the knee is definitely have its ba back sides or, or, or, or, or drawbacks or uh dark side. And the dark side or complication is won't break down, delayed or nonunion. And it's about 10%. To be honest, it's very uncommon to have an ankle fusion on no. Mhm. Especially if you're doing um uh fluoroscopic ankle fusion. The risk of risk of, of, of a failure of fusion or nonunion as any nonunion is high in smokers or in revision cases, um is low. There is not look for continuous trabecular to see if the ankle uh has been fused. Definitely a infection malalignment and the major problem behind the ankle fusion is diffuse a segment which was moving. So rather the patient was having the, the movement of the ankle and hind foot from two joints, which is the ankle and subtalar, you use the ankle, which means you lose the subtalar more than normal and, and as any as any uh joint fusion form at anywhere. It always caused an excerpt of the nearby joint uh arthritis. So the commonest problem you explained to your patient when you're offering him a fusion is the Subtalar arthritis will be extubated and will be very, very commonly to happen very quickly. So, and he will need a subtalar fusion at some point very soon. That's why Subtalar arthritis is one of the indication to replace rather than to fuse. So again, with the fusion, the main problems you will see in the practice is number one exerbation of the subtalar arthritis and need for a subtalar fusion very soon. The second problem if if you put the fusion in the wrong position, especially blunt reflection, patient will have nonunion vision will have a painful fusion. So how we use. So we have to do uh we can do this either open or arthroscopic. Both now are valid options. Um open we can do from anterior approach. From lateral approach. From anterior approach, we bought this anatomical blade as you can see from the lateral approach is a good thing. We get the fibula off and we use the fibula as a graft into the joint. And we bought a lateral plate. We can uh with the arthroscopic fusion, we can use a couple of screws. As you can see either ba the screws or cross the screws. And actually with these compression screws, the fusion habits very uh rapidly and very safely. Uh arthroscopic help us with minimal soft tissue dissection. For an open or lateral ankle fusion, you need to open a very big incision, either anterior or lateral. And this is as we understand the skin of the distal tibia especially is depending a lot on the perforators coming from the bone. And for a long long incision and large dissection of soft tissue. The risk of your wound problems and wound healing problems is very high. That's why we, we, we tend toward the arthroscopic um fusion rather than the open fusion to save the soft tissue, especially if the the soft tissue are already poor or we have a poor blood supply or diabetic patient. Number two is the arthroscopic um uh debridement or arthroscopic preparation of the joint. Keep a lot of the stem cells inside without getting them out like an open uh wound does. So it gives a better chance of healing a better chance of fusion. And it's definitely quicker procedure and less uh less bleeding. As you can see, the evidence says that uh both of them will unite in about 12 weeks. Nonunion is very low, about 7.5%. Only the last form of arthrodesis when we use it in AAA salvage procedure, especially in diabetic or if we're going to fuse the ankle and subtalar. And that is the time we insert a hind foot nail from the calcaneum up to the the and up to the tibia. So fusing both the ankle and subtalar joint. And this is commonly used in diabetic patient in reconstruction patient, in patient with poor blood bone quality. In patient, we uh we need to fuse both ankle and sub and we don't care about uh the joint spaces. Other side is ankle replacement. And we understand that as any replacement, we do them definitely uh um to get the patient back to normal function, not like fusion, which will fuse segment of the of the of moving segment of the hind foot. Number two, with the patient, as I told you have a subtalar arthritis, which means if I fuse his ankle or her ankle, I will end by the subtalar arthritis progressing very, very rapidly. Uh We use it commonly now with the rheumatoid patient and it do it does very well and definitely because we are not confident with the results of ankle replacement. Um At the moment, we keep it only for above 66 low demand mobile joint have a good bonus stock in enough stability of the ankle. And we tend more to do the varus ankle rather than the valgus ankle. I'll explain you now why when not to do a replacement as any replacement, you cannot uh do a replacement in a neuropathic joint, you cannot do a replacement with previous history of infection. You cannot do a joint with VN, you cannot do a joint with ligament, uh laxity or rupture because honestly, the the the the the ankle replacement or whatever replacement is not inherited in itself and constrained options had has its own problems. That's why you have to have a good ankle ligaments before we you replace an ankle. Then last one is normal alignment. And now we have options for that. But we tend to be away from uh especially valgus angle, severe uh valgus angle above 15 because severe valgus ankle above 15 equal that the deltoid ligament is not efficient anymore. And without deltoid efficiency, ankle replacement will fail. So we tend not to replace the ankle if there is Ron and malalignment, more than 15 degree in valgus. But while in vs, it's easy for us to reconstruct the lance ligament. But our media ligament reconstruction is not the greatest. That's why with a severe valgus, deltoid will be attenuated or ruptured. So we don't tend to replace this ankle but to fuse it, uh ankle replacement has passed by a lot of stages that it it early has a very uh bad repetition saying that ankle replacement, not like the knee, not like the hip, but actually because the Hi Hi and knee is more common as I explained to you at the start. And because they are commoner, uh they have a lot of development, a lot of EMT uh improvement, a lot of uh research and experimental work going on. But because the ankle is not commonly to have a primary arthritis, this is not the same for the ankle. It was by three generation. First generation was very highly constrained as you see on the left side because it's highly constrained, there's a lot of stress on the interface. And to understand this point, you need to understand that every joint and this is applies everywhere, not only for the ankle, ankle, hip, knee, whatever, shoulder, whatever you balance between two points, stability and loosening. So if you want to get your um uh implant or your joint stable, at, at the same time, you don't want to be very stable. Because if it's very stable in itself, it bought a lot of ST between the EMT and bone interface. And this is in by uh uh lysis or loosening. So you need to balance between getting your uh joint or your joint replacement stabilized and stiff compared to getting it loose. If you get the, if you get the, the, the joint highly constrained means it's very stiff in itself very stable. This means putting a lot of stress between the stem and the bone, uh what, what we call the stem bone interface. And this will end by an early loosening. It was cemented and it was always have incongruent body. It's a very thick body, taking the shape of the emboli and not the congruent. Then we pass to the second stage, which is from, from this position to another position. When we started using uh the Gerty and Gerty was a whole body tibia. So there is no metal component and it was bo coated. So this it wasn't cemented. But the problem is uh there was very high incidence of wear of the body. And that's why there was a high failure rate and very poor long term follow up. Then we move from this stage to stage three, which is thought we have the mobile bearing commonly the star and when we speak about the star, which is the, the, the the Scandinavian total anchor replacement. It become talar component do uh t component tibial component and a body in between. And they keep ta and tibial component, uh uh a couple of chrome and they are bos coated. So it's uncemented uh implant and they keep a small ridge as you see here in the tape in the talar component, which makes this poly I although it is mobile bearing, it has done some degree of restriction of the bearing. That's why it doesn't dislocate or have any problem. So again, me component to the TIA site which is Cobalt chrome and has some uh uh uh boros coating. So it's, it's fixed it very easily. And again, the same for uh the talar component that a bony in between which is very conform, there is very conformity as you can see is very congruent. So the body is very congruent, not just a box like before. And we keep a small ridge in the, in the TV in the talar component just doesn't, doesn't allow this body to go anywhere just to be mobile bearing. But in single track, this is, has developed more with the infinity which we are using now, which is the commonest uh emb used about 60% in UK. And you can see we increased uh the bos coated, it has a small big there and this big just stop it in place. So with the small big and uh big in this, in this configuration, this gives the Embron a lot of stability. So, Boru coated three bigs and the three Bs just insert inside the tibia, keep the embryon very stable, same two bigs for um uh uh the talus. And as you can see the talus, talus is more uh uh curve it according to the talar head to resemble the tailor head. And as you see, the body is very uh congruent with the talar component. And again, there is a very small ridge hair which allow the, the which though it is a mobile bearing is not fixed bearing, it is still moves in one tract doesn't go in or out. And the risk of uh of body dislocation or body displacement is very low. So what's the, what is the situation at the moment? Where are we? So if you see this, the, these two studies coming from where the uh you know that they are on a big arthroplasty unit. So in B GJ 2003 and 2008, they found that the five year survivor was about 92%. Yeah, it is not great. Great. Like the, the, the, the, the, the hip or the knee, but 92% is not bad. Ok. This 92% went down to 80% after a, at 10 years point of time and at 15 years it become 76. And they found that the survivor of the emb of ankle replacement is better in rheumatoid than osteoarthritis. Uh, to 82% compared to 68%. If you have a look on the N gr in 2020 22 we have done uh 93 933 cases all over the UK. The commonest emb used was infinity about 60% and inborn about 10%. And the difference between infinity and inborn that the in bone has a stem in the tibial side and the talar side is smaller. So inborn infinity, as you have seen, have you seen in this picture? It's just the borders quoted three bigs and borders quoted two bigs on the talar side in the, the, the in bone is exactly the same as the infinity. But the difference is, it has a stem in the tibia and a smaller talar component revision rate at 10 years was about uh uh 9.9 in males and 10.17 in females. And is the, the most interesting point is in, in, in young age below 66 it's about 12 to 15% while above 75 is just 3 to 4% at 10 years means 9596 to 97% of the implant. Um, didn't go for revision after 10 years, which is a very, very good results if you look at the em emb survival. Uh, so for every individual Embron you can see that infinity at seven years. Uh at 96% survival inborn at seven years for uh 96 survival solved to at uh seven years of 95% survival. So what's the principles if you, if you plan to do an ankle replacement, the most common approach use is the anterior approach. So uh it's a long incision, you aim uh to keep uh your skin detention because again, we, we're dealing with the distal tibia and the distal tibia skin depend on the perforators from the bone uh uh for its blood supply. So you try to get a very long wound to avoid any tension on the skin. Edges. Avoid use any retractors because any self retaining retractors. But a lot of tension on the skin and this is devoid the skin from its uh before to blood supply. And this is makes the skin problems are much, much more commoner. Uh You make a thick skin flap to avoid uh any problem with the vascularity. You to minimize the use of retractor as I explained to you. So, uh the complication from uh uh ankle replacement is definitely one of the infection as any replacement fracture. And common commonly the in ob fracture come from the medial mal. This is this, this complication is much less now because we're using now an an BS I or patient specific INERI which gives us uh a template to where to cut and this is uh gets us away from uh fracturing the medial mass. Then as it luing on osteolysis, medial gutter bin and, and this is very commonly, if you don't clear the medial gutter after you do the replacement, then uh fracture of the body and VT E. So if we compare fusion to to total ankle replacement, we're still saying that fusion is the gold standard, but total ankle replacement, as you can see in the previous uh um slides is doing very well and getting more and more shared in the in in the market. So if we speak about comparing fusion to total ankle replacement in ankle arthritis, we cannot ignore the ta trial. And a trial is a UK. Pragmatic trial have been done multicentric in, in two bar groups open labeled randomized trial. Uh 17 center has joined this trial and it was 52 weeks follow up. So it compared both total ankle replacement and an fusion and it, it compare uh both both of them regarding uh the functional outcomes and the clinical scores. So it found that both options are valid, functional results are comparable. Uh total ankle replacement has some more wound problem than the fusion and some nerve injury problems because it's a more bigger wound than the, than the um uh an fusion. But on the other side, an fusion has more uh VT E events and nonunion as I explained to you. And sometimes, sometimes it a is asymptomatic in about 70%. It is when, when they done a prospective controlled trial, this, this trial was done in 2009 and it has been published in the Foot Ankle International. It compared as T versus ankle fusion. So before the infinity in the market and before the infinity takes its share. So 24 months since we found that ankle treated with a star has better function and the ne nearly um uh equal results regarding the band release compared to the fusion. So from ta trial and this prospective control trial, we can say that fusion is comparable to replacement and if each one of them had its merits and challenges, but again and again, ankle replacement is getting, be getting better and better. And with the EMT uh development with implant improvement, the anchor replacement results are better and better. And as you can see, the NG ra is uh 96 years survival at 10 years, which is something very, very promising. So with that was ankle arthritis. And uh if we start to speak of the ankle instability. So ankle instability, uh you know, one of the most common sports injury is ankle sprain and ankle sprain. If it's uh maltreated or um ignored or missed ankle instability will be the answer. So patient will come to you complaining from giving way. So ankle is not that stable. He doesn't depend on ankle doesn't trust his ankle to walk. Sometimes it's just painless and this is commonly with the patient. Uh uh um uh bit common with a patient with hyper mobility. If it become painful, you need to think about if something injured, especially uh osteocartilaginous injury or have uh osteoarthritis from recurrent instability and recurrent injuries. So, ankle instability in its nature is painless if it become painful, think about ha get an MRI scan. Think about having an osteochondral lesion, brain injury or osteoarthritis. The most important when you examine a patient with ankle instability is to do a bit score and bit score to diagnose the hypermobility. I'm sure all of you know it. And if the patient hyper lacks this is gives us two ideas. Number one that functional rehab is very, very important and can solve the vision completely. Number two, if I will operate on this patient, I need to consider putting an intended brace rather than just anatomic repair because if the patient hyper lacks the ligaments are normally for him hyper lax. And if the ligaments are normally hyper laxed anatomic or anomic reconstruction will not solve his problem. You do your normal examination have a look on the vision from the back, from the side, from the, from the front, exclude that the patient has any deformity, which is is bosing for ankle instability. Like a patient had high foot virus with high foot virus division, putting a lot of stretch on the lateral structures. So lateral ankle pain is very expected for foot over subtle cavs. So any deformity of this makes the ankle unbalance. It both stress on one side of the ankle rather than the other. And this is the debate is both for anky sprains and instability. Definitely you need to do the anterior door and virus inversion, anterior work to examine the ATFL and virus inversion to examine the CFF. So types of anchor instability is is uh you need to understand it's not only mechanical, sometimes it's a function anchor instability because of uh loss of progress of the sensation, loss of balance, um um loss of protective reflexes and anything of this will give the vision a sense of instability which we call functional instability. Definitely the commoner is to have a mechanical instability because inefficient ligaments or ligament injury or ligament rupture or whatever. If we speak about the anatomy, we spoke about this before we'll go quickly through it. So normally your hind foot is in five degrees vuls and goes into varus with the inverters. Why is it it's naturally in five degree vuls because basically your invertors are more stronger than your verts. So the inverters, which is the tip and, and tip post are normally stronger than the eter, which is near as strong as per previous. That's why your ankle naturally is in five degree vuls. Because if it's more, if it's in virus, the invertors will be overpowering while they are already stronger. So your nature gut gives you an ankle in five degrees vuls just to balance this balance, the overpowering of the stronger T positive. And as an inverter compared to be strong and be previous as an e with capable virus, we understand definitely that the risk of instability would be high as we, as I explained to you when the hind foot is in virus means a lot of stretch on the artery structures means the artery structure are more prone to have an injury. We have uh the ankle ligaments is two joints, ankle is not only one joint, it's a s in this most, which is tibiofibular joint and then the tibiotalar joint. So with the tibiofibular joint, you have three ligaments, mainly the A I TFL bi TFL and um the interosseous uh A I TFL is the most commonly injured though it is the most strong but it's most commonly injured because the commonest injury is in extended rotation. So if you go to log enhancing classification of ankle fractures, you will realize that the ankle fractures commonly happen in external rotation. That's why the four types you have subin pronation, subin abduction, subin external rotation, abduction oration, external rotation. So external rotation in both subin and ation is the communist. And because of the extended rotation of the communist, the IA I ATFL is the most commonly injured in syndesmosis. The bi TFL is is more commonly to be injured in the highest brain. Then we have the interosseous ligament in the synthes mode itself and interosseous membrane between the tibia and fibula supporting it. On the lateral side, you have the, the AFL ATFL which is the anterior fibrillar ligament is the most commonly injured ligament in the lateral ligament. Um lateral ankle ligament complex. It's the weakest of them. It's just extending from the anterior colle of the lateral maus going into the neck of the talus. And it's mainly a a restraint against inversion and it works more when the ankle is in blunt reflection. That's why we examine uh the anterior drawer while ankle is implant reflection and we do anterior drawing um talar tilt if the, if the, if it's incompetent. So if the, if your anterior talofibular ligament is incompetent, this will allow your talus to tilt inside the ankle, not to shift to tilt. Uh B TFL is very strong, very, very uh um rare to have an injury. Then CFL, which is restrained mainly against inversion, either in neutral or dorsiflexion. And we examined it by both the ankle in neutral and trying to invert. Then you have the lateral arterial calcaneal and this is deep to the calcaneal fibular. And we consider it is part from uh the calo fibrillar. On the major side, you have the diploid ligament. It's about, it's a superficial and deep part. Superficial part is three parts. It's tibial, navicular tibiotalar and tibial calcemia. And the bar is just a thickening of the capsule. And it's this, it is anterior and posterior tibiotalar. So, superficial three bars, tibial, navicular tibiotalar, tibial calcaneum and deep one. And the superficial is mainly against a version and the bar which is thickening of the capsule and it's anterior and posterior tibiotalar only and this is mainly against external rotation. So barfi one is against aversion. Deep one is against rotation. Um on the bladder surface, you have very commonly the plantar fascia and the most common uh uh ligament which is the spring ligament, the calcaneonavicular ligament and this is goes from the inte tli this one go from the tech and t of the cal up to the navicular and the tar head is resting on it. So how you, how you test for ankle instability is the number one, it's mainly a clinical diagnosis. So if you exclude hyperlaxity by bit score and you assist the ankle, you see that anterior grow and virus invasion are positive. So your clinic, since your clinical diagnosis is the most important, then if you do a stress view the most commonly status view is to both the patient weight bearing and with the patient weight bearing, you can see some talar shift or talar tilt. And definitely you can do a stress view in the form of hanging from hanging uh uh foot from the table, external rotation or external rotation stress view. And this is will give you a a more picture about any uh injury to the media structure. Definitely the gold standard is MRI scan and the MRI scan. Uh we tried after we failed conservative treatment. So once we have a patient with ankle arthritis, sprain or ankle instability, we send for functional rehab, proper active and balance exercise by physio. And if this all fail, we get the vision to MRI scan, uh how you'll treat an ankle instability. So with acute injury, it just non operative measure and they are very, very successful. So rest the patient in booth do some physiotherapy with probably and balance exercises and uh muscle especially then operative treatment. If we plan to operate on that, we operate either by anatomical or non anatomic repair and we don't operate on ankle instability very commonly unless the patient feel all and we exhaust all ways of conservative treatment or if the patient starts to have problems like O CL or something from uh the ankle instability. So and before we do that, we need to show that MRI scan showing what ligament is injured and we've done everything before we go ahead with chronic injury. Definitely there is no uh space for non operative treatment though we tried them still. But we know from if it's a chronic injury that communist will be going for operative treatment, an operative is either reconstruction, uh uh and reconstruction could be anatomic reconstruction means we get the ligament back to its place using anchors or repair. If it's midsubstance injury, nonanatomical means we, we get something to do the job of the ligament, we don't repair the ligament. So if we speak about the anatomic repair, the common is Boston gold and Boston gold is pros basically got the ATFL and CFL got them back and insert a couple of uh of anchors into the distal fibula and both the back to the insertion of the foot prent. So it is a form of anatomic repair of ATFL and CFL. If the patient is hylax, if the ligaments are not that efficient and strong for repair, then we can use an internal brace, which is an artificial ligament done uh by Art Felix. And this is go on the same in the same plane of the ATFL and do the same job. And sometimes we use it just to support the anatomical repair. So we do an anatomic repair, get an internal brace to support over the anatomical repair. The gold modification of prosom is he repair the extensor, the inferior extensor retinaculum. And actually with the gold modification, the results of prosom become much, much better. So the the trend or the common practice at the moment is prosom gold, which is anatomic of ATFL and CFL back to their footprint in the fibula and then both the jacket from outside or support from outside or seat belt from outside in the form of internal brace. Definitely we can do this open and uh and arthroscopic and but arthroscopic is very uh uh uh fancy. So it's not that common practice. The commonest practice is to have it anatomically. This is anatomic as you can see, this is post goal. So we b the ligaments back to this, their foot insertion using two couple of anchors, then nonanatomically you have two options. The option number one is events as you can see events, we we cut the S Brevis, both it through a tunnel in the distal fibula and just uh hold it in the back. So the, the distal part of the Brunnius Brevis is doing the job of E TFL. On the other side, we have uh uh uh uh the Christmas knock. And with the Christmas knock, we just split the Bene Brevis uh into two and take the anterior part bus it through a, a tunnel in the fibula and hold it on the posterior part. And by this way, we keep the action of the Benes Brevis working and use the interiors from the Berne as uh ATFL. So this is the healing instability this ankle instability if you come to the third common uh topic and the third one of the most common presentation of patient to the foot and ankle clinic is heel pain and heel pain, as you can see, has a lot of differential diagnosis. So if you have a heel pain, you may have a Calcaneal spare and CALC spare can be blunted or can be posterior and a spare. Basically because there is a lot of micro injury at the insertion of the and the fascia or the ligament. And with the micro injuries, there is a lot of inflammation and this inflammation recruits calcium to come and breed these bones here and this wide the spare form it, you may have a fat back atrophy. You understand that you are not walking on your heel directly but you have some fat bag here and this fat bag can be atrophied. And if it is atrophied, there is more contact between the calcium and the and, and the, the ground. And this is where the pain is. You may have achilles, adenopathy and achilles tendinopathy could be insertional at the site of the insertion or could be non insertional and you may have a calcaneal stress fracture. And it's common in people with the steroids common in people uh during puberty, common in females. Uh and osteoporotic females common in people who are doing a lot of activities, uh especially if they are stressing the calcium, then you may have a hagland deformity and this is the hagland deformity. It's a bony prominence here and this bony prominence causing these tendons to uh to rub against it and cause a very commonly uh insertional an tendon achilles, tendinopathy which may end by rupturing of the achilles. Then you may have a posterior ankle in Benjamin means you have an osteophyte here. That's why the ankle is posteriorly impinging. And this is cause uh give, give the patient a heel pain. These three involved, they are the uncommon causes of heel pain, but they are still happen and they always missed Baxter nerve entrapment, joggers, foot, spheres, foot and blunt fascias if we come to the Baxter nerve entrapment. So, Baxter is the first branch of the lateral uh uh blunter nerve. So this is the la lateral blunted nerve. It gives one branch to go back here. And this branch is the Baxter nerve and this is basically uh uh uh innervating the abductor digiti mi and, and the rather than as he need, they get compressed here between the abductor hallucis longus and the median side of quadratus pl. So where he both in his thumb, this is between uh the the abductor hallucis longus and the media side of quadratus plan. And this is where the Baxter nerve, which is a dorsal uh branch from the later Alan nerve gets compressed, patient will heal vein and this will need us to go and release the abductor halos fungus Jogger's foot and basically nerve entrapment was the lateral planter nerve. Jogger's foot is the media Blanton nerve and it's always compressed at what we call not of Henry here where the F DL and F HL just go across each other. This is a common side to compress the media Blanton nerve and gives you what's called jugglers foot. And the main treatment for this is to, to release the compression by foot, Ortho. And if it doesn't help to go and release the north of Henry, see this and uh a lot of you see this in excret immature, as you can see it, a lot of fragmentation of the posterior chro or what we call the apophysis. So I'm sure all of you understand that epiphyses is end of the bone and ops is where the tendon or ligament that touches. So here, where is the achilles that touches? This is the, the cal apophysis and it's common to have apophysitis and the skeletally immature especially um the the very active Children doing football, a lot of repetitive microtrauma, they get uh their above this is uh uh uh fragmented as you can see. And there are a lot of pain and this pain always settles when they are um 18 or plus. And if you have any doubt about it, get an MRI scan to exclude any underlying problem, especially fracture and the treatment is very conservative. So just rest heel. But uh if you need some casting and in very, very rare situation, you may need to uh stretch in the heels, plantar fasciitis, the commonest and the most worst uh complaint you would see in foot and ankle clinic. So when you are a foot and ankle surgeon, your worst time, when you have a patient coming in saying I have a plantar fasciitis though it is very, very simple, very simple pathology, but unfortunately, very resistant to treat and patient. Uh uh You'll be surprised if I told you that plantar fasciitis is self-limiting means if the patient leave it alone, it will settle at one day. But when this is a difficult question. So blat fasciitis or DNS Hill. So any it's called B Hill because there is a stretch on the blat fascia in the dancers. And as I told you, the surprise is the plantar fasciitis is a self limiting problem. But the problem, it is irritating. The patient all the time, painful patient cannot walk normally. And uh patient is keen to try different modalities of treatment and it is very resistant and you may try every treatment and and sometimes it never responds. Uh patient will come with all age commonly heal back, uh stiffness and blunt and fascia, thickening, thickening. Um uh The common occupation is the patient who is standing for long hours, people working in airports, teachers, uh the people uh cashiers, the people who are uh on feet all of the day it is commonly to be a start uphill pain and very common. You remember that very common uh complaint or of, uh, the first few steps in the morning are very, very difficult. And once I start walking, it's ok. And this is b basically because overnight when you're relaxing, your foot is like that when you're sleeping your foot at the end of the day, just relaxing in Blann of flexion. So the plantar fascia is relaxing with the first system in the morning, you stretch the blatter fascia and that's why you start up pain uh in the morning is very common. Once the patient start to walk, the blan and fascia start to be stretched. The, the pain is less and less. That's why pain is very commonly in the morning when you examine because the patient is in pain in the heel. The pain patient will avoid to do a heel strike and added to that achilles is always tight because the patient doesn't do complete uh dors flexion. If you feel your feet, some tendon, some tendon is over the bladder fascia, especially at uh near the insertion. And if you test for the achilles tendon, you'll find that the achilles is tight, either from the gastroc or from the achilles itself. And this is differentiated by several tests. But uh because you understand that the fascia is underneath the foot and then attach it to the prostate and going in continuously with uh the achilles. When the achilles is tight, the blat fascia is under the stage. And to be honest, from my own practice, releasing the gastroc is very, very helpful to the patient who has tried all non operative treatment and hasn't responded so bit of anatomy. You understand that it's, it's uh the plantar fascia originating from hair, not inserting, be careful originating from the medial uh calcaneal pros in continuity with the achilles. And then it goes into central band, lateral band and medial band and uh central band goes into the three toes, uh media band to the middle, uh to the little toe and then I'm sorry, lateral band to the little toe and medial band to the head. The function mainly as you understand is to create the media longitudinal arch and to do the winless effect. So with limited trauma, commonly at the insertion site, this in insertion site start to uh have a microtrauma with microtrauma healing inflammation and this is gets very inflamed and painful and that's what recruits sometimes calcium and causing the C spa. You diagnose it mainly clinically and you will never miss a patient with blunt fasciitis and he will never miss you. And other than this, you can do an ultrasound to see if there's any thickening in the in the bladder fascia. And definitely MRI scan is a um is a modality of investigation, uh treatment, very painful, very painful for the surgeon. You send the patient for all forms of treatment and they always can come back to say, oh, I didn't get any improvement. So starting from uh, show modification, have some heel bags underneath. Try to avoid longstanding, uh, uh, a lot of options of injection, steroid injection, which is very risky to rupture the, uh, the L fascia. But sometimes they help if one injection, extra copay of shock wave P RP injection, all these options and you have to try all of them once or twice. And for a good time before you commit, you commit to a surgery because surgery is not, doesn't have a consistent uh uh results. So results are not consistent. Some people get a very good help from the, from the uh release or the linking of ait, some people doesn't go any treatment or any, any improvement. So I've seen patients who come in sever is going positive achilles is died and they ask for gastric release though. The vaso say no. And with gastric gas, gastric release, they are very happy and plantar fasciitis is very, very better, much, much better. On the other hand, people who have very clear indication, good indication, we do release of the gastric or lengthening of the achilles with a trial or whatever procedure and they still uh in a lot of pain and doesn't get any improvement. So, plantar fascia, one of the headaches of uh for the ankle practice end of the end of the corridor is a surgical treatment of all non operative fails and surgical treatment. As I explained, you will be either approximal gastro release or um um uh lengthening of the achilles or on the other side, if you want just to debride or even to um uh release the plantar fascia, commonest condition in all exams in all uh, foot and ankle clinics in all um virus in all orals is helix valgus and your foot and ankle question in the Fr CS in part A uh would be mainly Helix valgus. And in bar B, Helix, Valgus and flat foot are very, very common to come in the examine. So the patient, he will come to you to complain mainly either from the bunny itself. So this bunny will be inflamed, hot red tender and difficult to put the shoes on uh or he will come to ex to to complain from trans metalia. So to understand the transverse tosia, normally you put first weight on the uh ball of the first toe or uh uh head of the first met tarsal, then it goes across to the fifth. So normally what hits the ground first? And what takes the weight first is the first meal. And if this first metals hit, not in place dorsiflex, it because of uh on the function because of he the patient uh put more weight on the 2nd 3rd and force and this is close transfer me means because weight has been transferred from where it naturally is, which is the first metatarsal to 2nd, 3rd and force which is not naturally loaded. This when the metatarsalgia or pain under the metatarsal hits happen. So patient will come to complain either from the body itself, hot tender swelling or he may come uh to complain from to to Yeah. And this because normally again, when you put your foot in the ground, first thing to get the weight is the first me to head and then the arcade after that get some weight, but the main weight goes to the first me to head. The first meter to head not embraced because of the Haddock Valgus. This means all the weight will go to the 2nd, 3rd and 4th or lesser toes. And this is when the trans meal happens. They may come as you see in this picture with deformity of the laser to secondary to the Hallux Valgus, which is commonly the hammer to and to understand why the hammer to happen with the Helix Valgus. Basically, basically, if you can see now this is, you can see here the Hallux Valgus happens once the hallux valgus happens, this is now rotated into ation. So the Cymoides are displaced, they are not putting weight, uh they are not getting weight anymore. And this and by but a lot of stress here and because the, the the the, the val deformity doesn't give any space for the second two. The second two reflexly get into the uh extension or hyper extension at the MTB joint. And with the longstanding hybrid extension here, the blunt, the blades start to attenuate and once it's attenuated, the, the joint, the the the toe go in this hammer position again, had me first metatarsal head is dorsiflex. It is not touching the ground metatarsalgia with the helix vs ation, the cymoides are displaced and because they are displaced, they don't get normal weight. And from that, this is all the weight is going onto the laser toes with the helix valgus, deformity, there is no space for the second toe. So second toe is continuously elevated and because it's elevated, this attenuate the blunter plate and in the by by hammering it to or uh uh fix it uh um do fix it, dole it to or extend it to when you look for a patient with. He Fergus, very, very important to have a look in the shoes and you will see the shoes resembling the same shape of the foot. So their shoes will be having a bump here and there is a big pointed uh tip, tip, um two box from the front, there will be prominence as you can see either here in Harris, uh the, the bunion or underneath the vitals heads, you will have some pronation of the big toe as you can see. So this big toe is not straight. If you look to the nail blane compared to this nail blane, this is pronated, this is, this nail should be better to this nail, but actually, this is burn um overcrowded to as you see calloses under the metatarsal heads because of transform Tosia as we explained. So how you examine. So you have to see the patient again, same, same protocol patient is standing walking then from the back, then from the side, then from the start from the front. So when you have uh look at the gate, so very commonly to have associated flat foot with Helix Valgus. Uh if you feel um vision with standing seriously with the patient standing, you can see Helix um heel valid. Uh uh too many, too many two signs collapsed arch and definitely cannot spot the hes deformity and the less of twos deformity on uh looking from the front. When you put your hand on, there is tenderness over the bunion itself. And when you start to move, um the the the joint, maybe the joint painful because of uh associated some atb arthritis or maybe not painful, you have to assess if this is um Harri Valgus is correctable or not. Be because this gives you two ideas. Idea. Number one, will you need to do a soft tissue release in the operation or not? And give you an idea if the joint is still congruent or not, you have to test the for the T MT joint. It's, it's mo it's mobility and movement. If it's painful means it's the first T MT joints, athletic if it's hyper mobile. So means in both, in both situations that you need to do something for the uh the first T MT joint to, to address the Harris fungus, you cannot address the Harris works from distal either by osteotomy or fusion. While the T MT joint is hyper mobile or ari, then the test you do is a grinding test you see in this picture. So basically you push in and you start rotating the toe. And this gives you an idea if there is an arthritis in the MTB joint or not. And this is will answer one of the question about the treatment saying if you have an arthritis here, there is no point to do osteotomy. So you can correct the helix valgus and the helix regions, which is arthritis in the first MTB uh by fusing the first MTB joint, very important to test for tender achilles, ensure if it's tight or not because if it is tight and several is positive with achilles tight, you overload the forefoot. And this is add to the problem we explained about uh hammer to an and me definitely the neurovascular situation and better score etiology. So there is no uh uh fixed point of etiology. We know that there is uh some uh uh inheritance background. It is very common to run in families, especially in female. So it's very common for uh for females to have um to have it inherited from mom or aunt or uh grand mom. And other than this, there's a lot of factors, environmental factors which add to the inherited factor in developing the hallux valgus. So uh like a high heel shoes, if you're using a high heel, you're both the foot in this position position already. And 4 ft overloading. Uh as we have told about flat foot ligament, laxity and rheumatoid if you come to bass anatomy to understand. So the situation start with a media attenuation, medial capsule, attenuation with the medial capsule attenuation, the the Phalen deviates laterally. And because the pharynx deviates laterally, this is moves the whole thing as you can see, move the whole thing away from the cymo rather than the cymo was centered in the cymo joints on the CMO foci is away from the cymo and this is moves all the muscles on this side to this uh to to to more virus. And this is disturbed the whole mechanics around the toe. So media media capsule attenuation this end by the helex deviating into uh laterally meth head, displaced media against the the the if you imagine this is the helix valgus. So if the pharynx is going laterally, this means the head is coming immediately, Phx is going lateral head is coming media and with Flix going lateral because of attenuation of this media capsule, this will take the CMO with it. So the cymo is attached to the flexor um um hall previous and this will take the CYO away. So the loading mechanism of the, of the, of the hallux is be become abnormal and this cause imbalance between the muscles around the hallux. So once it, that that's done, the abductor, abductor tender rather than being abductor become because of these places, it becomes an abductor force. So it's adding to the varus deformity rather than correcting it, everything will deviate to lateral deviation of EF HL and F HL. And this is makes them more vulg deforming force rather than just extending or flexing force. Media, attenuation of the capsule. The pharynx goes laterally, the head comes immediately with the phni going laterally, it b the CID with them because it attaches to the FHP with the CMO moving this way, all the muscle around the headaches become imbalanced. So the abductor become abductor, E HL and A L are going other than rather than being extending and flexing because the pharynx is going lateral, it will be more of a deforming force. It's causing more vuls. This ended by prominence of the media side by, by the me, the uh I'm sorry, media deviated media head. This is when the bunion, correct. So we diagnosed it with weight bearing X ray. We have to um draw some lines and see some angles. The most important for us is the had s angle which is between the long axis of the B1 or the of the proximal fx and long axis of the miara. And this is should be normally uh below 15 degrees, 16 degree. Then you have the interm metatarsal angle. So between the longitudinal axis of the second, long axis of the first, which should be within 10 degrees. Then the DM MA which is the distal metatarsal articular angle, you draw a line you draw, this is the long axis, you draw a line perpendicular on the articular surface uh and the bar to articial surface, I'm I'm sorry, and the perpendicular on it. And this is the angle which is the DM MA. And again, we don't accept bef beyond 10. Uh then the pharyngeal angle, if you do draw an uh line along with the long axis of the distal femi and line along with the, the the uh long axis of proximal fRMI. This is what we call the interphasal angle based on these angles, you will decide your treatment. So if your problem is in the interm metatarsal angle mean the inter metarsal angle is open. So either you need to do approximal osteotomy or approximal fusion if your intermittent angle is reasonable, but the rix valgus angle is big. This is the time you need to, you can think about either scalp ostectomy or Chevron osteotomy. Then if you come to a severe rixs def form, the severe uh increased intermittent angle, this is you need to think about double osteotomy. So you may do something distant and something approximate the goal of treatment of Hadi Vargas. We are not plastic surgeon, we don't correct deformities. So if had vs is not painful is not affecting the normal day life of the patient, we don't operate. Our aim is to realign the first ray, get the first ray functioning again, not transfer metatarsalgia and to correct the deformity and to relieve the bundle. Uh if the patient has, we can do this to start with, with non operative treatment. So patient, to me, find the shoes, make the shoes wide two box, try to avoid long standing, try to use some arch support orthotics and some two separators just to separate between the twos and push the hallux back in normal. If this is do help, that's absolutely fine if this is doesn't help. So we have to go and correct. And when we correct, we need, as I told you, uh while we examining, we have a test if the had valgus is correctable or not. And this is to answer this question, will we do a mcbride or soft tissue procedure or not? So, if the had valgus is correctable, means the soft tissue needs to be released to get this correction done if it's not correctable. So there's no point. So mcbride basically modified mcbride. Basically, we go, we release all the lateral structure including the lateral capsule, the abductor helosis and this allow the tool to correct. So we go and get all the, we, we release all the structure, allow the, the joint and allow the tool to correct. And by the end of the operation, we do the modification which is location of the median um capsule which is maintaining this uh incorrect position. So mcbride advises to go and release the structure including the abductor halysis and um the abductor hallucis and the capsule. And the modified one is to repair and do ligation or tightening of the capsule on the media side. Then the types of operation very simply all hallux valgus can be corrected from a scarf osteotomy, except if there is first T MT abnormality. All hallux valgus can be corrected by scarf osteotomy except if there is T MT arthritis or T MT higher morbidity. I will explain to you why it's curved now. So first and the Communist um this the metatarsectomy is Chevron. And as you can see, Chevron, we make a V shape. This is the metatarsal. We make a V shape. This thing should be a bit longer than this to avoid the blood supply here. And then we just shift the, the, the head laterally and the shaft immediately and just it is very, very inherited stable. I all we can stick a screw in what the helix, what the Chevron does. It just correct the translation. So as we agreed, Flix is going laterally head is coming immediately. So all the Chevron does is just move the head back to lateral and the shaft to media and that's it. So it doesn't correct the lens, it doesn't correct the blunter and dorsiflexion. It only correct the translation. On the other hand, uh aching osteotomy is just a distal um uh closing wedge osteotomy, later closing, which media closing wo of a of, of the femi. So with ach osteotomy, you go, you cut here in the metaphyseal area of the femx and you do you remove a witch and you close the witch immediately. So you correct the interns angle scarf, which is the gold standard for, for treating all heals. It gives you a very versatile results. You can correct the translation as a Chevron, you can correct banter and dorsiflexion, you can correct rotation, you can correct whatever you want. Basically what you do, you do a a step cut like that go, this is distal and a transverse limb and approximal limb. And once you do that, you have the option. So imagine with me, this is this is the me person. Uh I'm cutting here distal going at trans and here approximately if my cut is this way means that when I move the head will go back, means I will shorten the middle tarsa. If my cut is this way distally, this means um when I move the head, it comes more prominent, I lengthen the meara the transverse cut. If I do it better to um uh better to the, the the first tray or the first tsa, it will not do any plan or dorsiflex, it just move it. But imagine if I do the cut like that, what will happen when I move? It just slips down. So it blan lies the first meter person and other way around if I go this way, start to move. So this is slips uh the metatarsal over the head. So it makes it more dorsiflex again, di di distal cut, transverse them and box. If distal cut, this is the metatarsal. If distal cut is this way means when I move the head, I'm, I'm moving the head from media to later means I'm lengthen the metatarsal other way around. If it's this way and I'm moving the head, I'm shorting the metatarsal, the blade, I cut the transverse limb. If it's just to the metal, the metal cell, there just translation. There is no movement up and down. Imagine if I make my hand like that and start to move this this way and that the shaft the other way. So I'm just izing. And if I do that, I'm dorsiflex to understand this. Well, there's no way until you, you try it yourself, get a carrot from the kitchen and do a cut on the carrot and try to do the cut straight, straight, straight, try to do a cut this way, this study or this way and see what it cleansing or not and try to do the cut, the transverse cut, perpendicular dorsiflexion or plantar flexing. Uh if this is, doesn't help or if the first EMT has any problem. So it's more uh to do with fusion of first T TTMT. The good thing about the fusion of T MT or Labidus procedure is it's approximal correction. So the bar of correction is very, very high compared to the distal correction. Uh If you have any degeneration in the helix, uh it become had rigidus, which means degenerated first MTB joint. The options you have either to fuse it, which is very, very commonly used in the gold standard or to do a car resection means you get both of the distal pni to remove and stick a wire in and you keep too floating and you just do an excision after blasting or to replace it. And we have a stylistic embryon and we have, we have before captiva. We have now syl embryon which are doing very, very well. What if you have a rheumatoid patient with Hallux valgus? So with rheumatoid patient b bone quality, more soft tissue quality, there is no room for the for uh uh realignment or osteotomy. So you always go for fusion of MTB and bay of the system. The communication we may have with osteotomy of the helix valgus is tring and to understand the tring. If you cut in a cortical bone, there is no way to trough while if you cut in a canus bone as you can see in this picture, once you move the two parts of the osteotomy, you can have this limb sking into the middle. And this means your cat is very deep. You have to have your cut, very superficial. So it is in cortical bone, not in can last bone to avoid any traffic risk of fracturing. Especially if you bought your screw risk of hallux vi virus, which is a big problem. and this is happening if we do an overcorrection, second metals, second me metal surgery, if I don't correct the blunt flexion as I explained, bid for neuromas, especially if you injure the nerve, the dorsal media branch of sur avas can cause of the head if you attack. Um If you attack the area of blood supply, which is just the blunted to the apex, regards, especially if the patient has an high but laxity and cock up deformity. As you can see if you do a killer or you do any injury to the F HL. This will end by what we call a cock up to HX virus is commonly to be a complication of helix valgus correction. Uh It's, it's rare to see it. Uh It basically, it's more commonly to be uh post surgery and to be honest, is one of the major problem the patient may have after overcorrection of um um of had valgus and very devastating because with the Hallux virus, it's so difficult for you. If you have a look on this, uh, foot, it's so difficult for you to put it in the shoes. So, Harris virus is one of the most difficult complication and most irritating to the patient and which she needs, uh, uh, needs a correction of revision. The main problem is difficult in wearing the shoes if you have been, this, indicate that this, the joint become athletic. If you can see, it's mostly commonly, uh, both had vs surgery if you do an overcorrection, if you do an ex excessive release or excessive tightening of the median. So either you do excessive release, laterally, excessive tightening immediately, um uh uh or you do a resection of the abductor hallucis, any of this will get the two into Hallux virus. And as I told you, it is one of the major complication. Thank you so much. So, a long lecture, I know. Um But yeah, Helix Valgus is very, very important, very common to come in the exams. That's why I was, I was keen to cover it as much as I can. Um, a scarf don't depend on any explanation. You have to go uh get a carrot and try to, to try it on the carrot to understand what's plantar, what are dorsiflex, what's shortening? What's so have a look on the go, you can see the, the shape of the cut or the step cut. And from this step cut, you can get an idea how to do but that is gonna car is to be honest with you. It's got one of the most difficult, one of the most difficult uh operations to do and you don't do it unless you are very senior because mistakes, if mistakes happens, it's a big problem. Uh And you need to understand the mechanics. You need to understand where to cut, how to shorten, how to long to lengthen how to do. Uh Blay, how to do uh do flexing. So a scarf, try to practice on a carrot before you practice on the patient. Uh It's not an easy, it's not an easy operation to myself. And to my understanding is 11 of the most challenging, one of the most um sting learning curve which needs more, more time. Uh from a lot of the seniors uh have been trained with, uh don't commit to do a scarf before you do. At least 100 100 will be a lot of mistakes. But yeah, it can be accommodated before you can say I do scarf to say I do scarf. You need to do at least 100. Uh I hope it was useful a bit uh um lengthy literature, but I'm very sorry for that. I couldn't make it any shorter. Uh I want to give you um as much as I can for foot and anchor before you go for the exam uh next month. Uh please. Um Both your feedbacks when you receive it So um uh mi all will be sending you feedbacks if he didn't and both your feedback, all the points you bought is very useful, very important to me and help me improving in the next sessions. Um I will see you next Friday with lecture number five. And uh I hope by this time, uh I'll have all your feedback and I promise you, I'll put all the points, you got the feedback into action. Uh You will receive your attendance certificate as usual after you send the feedback. Um And I hope you all um a very good evening and if there's any question, I'm more than happy to answer. There isn't any questions uh in the box now? Perfect. I II hope this is because the, the lecture was clear. It was, it was clear. Ok. That was very good. Ok, thank you. Uh Yeah, I'll, I'll not uh take more from your time since it's nearly um half 10. So, um uh enjoy it both your feedback and have a good evening and see you all next Friday. Thank you very much. Thank you. Thanks for your time. Thanks everyone for attending.